Proposed Revisions of Dementia Diagnostic Categories
for DSM-5

First published in Psychiatry
Weekly, Volume 5, Issue
27, on November 8, 2010

Out With the Old, In With the New

Delirium, dementia, amnestic, and other cognitive
disorders are subsumed in the DSM-5 under
the category of “neurocognitive disorders.”
Neurocognitive disorders, in contrast to neurodevelopmental
disorders, are acquired and degenerative rather than inborn
and apparent in childhood. The term was chosen in part to
avoid the stigma associated with dementia when categorizing
deficits among younger people with progressive cognitive
decline associated with HIV or traumatic brain injury.
Neurocognitive disorders are further divided into major and
minor. The DSM-IV condition described as
“age-related cognitive decline (ARCD)”
appearing in “other conditions that may be a focus of
clinical attention” would now appear under minor
neurocognitive disorder in the DSM-5. This is a
decided advance. Terms such as ARCD, cognitive
impairment not dementia (CIND), mild cognitive impairment
(MCI), amnestic MCI, and non-amnestic MCI—which
have variable criteria but are often considered a prodrome
of dementia—would now be listed as a minor
neurocognitive disorder. More importantly, in contrast to
those without detectable impairment, people with CIND
exhibit both a greater prevalence of neuropsyschiatric
symptoms such as depression as well as functional
limitations. Minor neurocognitive disorder is analogous to
minor depressive disorder, which appears in Appendix B of
the DSM-IV, along with subsyndromal
depressive condition not elsewhere classified (CNEC).
Indeed, subsyndromal depressive CNEC is further divided
into prodromal depression and subsyndromal, and mixed
subsyndromal anxiety-depressive disorder depending on
duration, severity, or associated features, respectively. Both
MCI and minor depression are similar in that they predict
progression to either dementia or MDD. However, many
people believed to have MCI or minor depression never
develop a major mental illness. The certainty with which we
can distinguish a symptom or performance profile which
represents a genuine prodrome from periodic variability in
cognitive performance or mood remains problematic.
Nonetheless, identifying minor neurocognitive disorder as a
DSM diagnosis reflects a growing consensus
that MCI and CIND are too often the early manifestations of
dementia. Additionally, not to have a “minor”
diagnostic category would leave investigators and the public
with the confusing terminology that followed in the wake of
the DSM-IV.

Cognitive Domains Mature

The DSM-IV identifies impairments in
memory and learning plus one of the
following—aphasia, apraxia, agnosia, or executive
dysfunction—as criteria for dementia. Deficits must
cause social disability to justify the diagnosis. The proposal
for the DSM-5 includes domains for
“complex attention, executive ability, learning and
memory, language, visuoconstructional-perceptual ability,
and social cognition.” Each item has a paragraph
describing major and minor deficits as well as definitions of
the domain and examples of assessment procedures.
Equally important are descriptions of how impairment within
the domain disrupts behavior and threatens independence.
The work group remains uncertain about how to formally
portray domain-specific deficits. However, it seems critical to
tailor the caregiver approach and structure the environment
to take advantage of capacities which are preserved and to
compensate for those which are deficient. Achieving the right
fit between strengths and vulnerabilities would presumably
lessen the patient’s disability, reduce the
caregiver’s burden, and minimize the occurrence of
behavioral disturbances.

Disclosure: Dr. Kennedy reports no affiliations with, or
financial interests in, any organization that may pose a
conflict of interest.